WINTER KYOLCHE 2010 - ONLINE REGISTRATION

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Personal Data:

First name

Last name

Birthday

Cellphone number

Postal address

Retreat Data:

Date you begin

Date you finish

Would you like a pick-up?

Time of arrival

Practice Background:

Do you pay membership fee to Kwan Um School of Zen: YesNo

Your Home Sangha (Zen Center / Temple):

Retreats you’ve attended (where and when):

Monastic Precepts:

Lay Precepts:

Your Dharma Name:

Precepts in other buddhist tradition

Day of Precepts

Month of precepts

Year of precepts

Food:

Do you have any special dietary requirements?

Do you have any food intolerance?

Health:

Do you have any allergies?

Do you need any medical treatment?

Do you snore? YesNo

Emergency Contact:

Emergency contact name:

Emergency contact phone:

Emergency contact email:

Waiver of liability: I the applicant as specified above understand that my participation in any activity of the Kwan Um School of Zen (KUSZ) is voluntary and I agree that I will not participate in any activity for which I have reason to believe I am ill-suited, physically or mentally incapable, or which I believe would create for me an undue danger of physical/mental harm. I agree to inform the KUSZ representatives of any existing medical conditions or previous mental disorders or events that are relevant to my participation in the activities. In the event of any injury resulting from my participation in any of these activities, I agree to bear all medical costs and I hereby waive and release the KUSZ from any claim of liability against the KUSZ or its members and subsidiaries, and indemnify the KUSZ against any loss suffered by it as a result of my injury.

By pressing the "Send" button you agree to the waiver of liability as above. Your personal data shall be protected and not released to third parties in any way.

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WINTER KYOLCHE 2010 - ONLINE REGISTRATION

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